SRQ: As allergists, how broad is your field? John Cella, M.D., Allergy Affiliates: It’s an interesting field, very wide. We’ll do food allergies, environmental allergies, insect allergies and skin allergies and rashes. That’s the bread and butter of my practice. There’s some immune-related, too: people with recurring infections, people who need replacement products to boost their immune system. But that’s more a minor part of my practice. Matthew Aresery, M.D., Intercoastal Allergy and Asthma: To expand on what John said, we do get a lot of overlap with dermatology, especially in the younger age group. Some dermatologists don’t see kids, so we see a lot of eczema, what we call atopic dermatitis, ones there are no real cure for, so it’s a matter of management. There’s no real cure for asthma, but we have to see people with asthma to keep that under control. The other things that we might see are anaphylaxis and patients that walk in and don’t know what they’re allergic to. We overlap with the ear, nose and throat doctors dealing with chronic sinus problems, at least as it relates to allergies. I get a fair amount of drug-related allergies. People come in allergic to some antibiotic and they need to take it for some reason. We help desensitize them to that.

What’s the thing that unites, for example, a food allergy to an environmental allergy and makes them both allergies? Cella: Immune reactions—the way the body reacts or overreacts to whatever substance it is. A lot of food allergies are the body overreacting to what shouldn’t be a noxious substance. So with the peanut allergy, we try to educate the parents and the patient about it, try to teach them avoidance. There are some modalities that can desensitize the patient, or make them less sensitive, and in the next few years, we’re probably going to see that more in the clinical level, more widespread. It tends to be restricted to the university level right now. But it’s really just the body’s immune reaction to these things in our environment. Aresery: A question I hear a lot from my patients is: “How long does it take to be allergic to something? Can you be allergic if you eat something for the first time, if you’re exposed for the first time?” The general paradigm is that you first have to be sensitized to something, exposed to something, in order to be allergic to it. In other words, you don’t eat a piece of something or get exposed to a flower for the first time in your life and have an allergic reaction. It’s a matter of sensitization, and then it becomes an overreaction causing a reaction that we have to treat.

Do we know why that happens? Do we know why the body will take offense to certain elements? Aresery: That’s a great question, and if we knew that, we’d be a lot further along with the treatment. We go to these meetings every year, and that’s always a question that comes up, and it’s one of those unanswered questions. The big thinking right now is what we call the “Hygiene Hypothesis.” We all live in a fairly sanitized environment, with antibiotics every time our kids get colds, and Windex and cleaning agents. Kids that live on a farm or in a third-world country don’t have that kind of exposure to those things and that actually leads to a better immune system.

What are the old standards for treatment that are still in effect? Cella: Allergy shots, allergy drops. Mostly for environmental allergies. What you’re doing is exposing the patient to increasing doses of allergen, initially in very small amounts, the body will make an immune response against this allergen and eventually becomes desensitized. You can’t do it for everything. There’s a lot of research now trying to desensitize people to foods. The issue is that it’s really polysensitization. In Florida, there are a lot of allergens. A patient might come in allergic to dogs, but they might also be allergic to a variety of pollens. We have very long pollen seasons here and it all mixes together. Dust mites are endemic here. We have a lot of mold. Avoiding it is going to be very hard. So you have medicine to treat the symptoms. A lot of times that’s adequate. If you want to get rid of it, you get allergy shots.

What’s the difference between getting shots and desensitizing yourself, versus just living with the cat and hoping the allergy goes away? Eva A. Berkes, M.D., Hawthorne Clinic and Research Center: You get a different immune response. If you can fake out your immune system by introducing it to a whole different arm of your immune system by skipping your allergic response, about 98 percent of the time, by doing immunotherapy you can normalize your immune response, as opposed to stimulating your immune response. Cella: With the immunotherapy, we start with very, very low doses because we don’t want to put enough allergen in where it’s going to stimulate an anaphylactic reaction. Patients come in regularly or take their drops in increasing doses. You’re acclimatizing the immune system to whatever this allergen is. And basically you can induce an immune reaction rather than inducing one of these full-blown allergic reactions. It’s very useful for people with chronic environmental allergies. Aresery: The difference is that we’re controlling the amount of exposure you have, how much allergen you’re getting.

A word that’s popped up a lot is “anaphylactic” or “anaphylaxis.” What does it actually mean? Berkes: That’s the classic severe reaction, for example, if you had an allergy to peanuts or bee stings. If a kid eats a certain kind of peanut allergen, then he or she might have a systemic reaction away from that local introduction of allergen. It can consist of hives. It can progress to the point of low blood pressure, shock and, in the case of the most severe exposure, death.

When should people go see an allergist, and not keep taking antihistamines or over the counter medication? Berkes: When it impacts their quality of life. If they’re waking up every day and they’re saying, “God, I feel awful,” they really should go. Aresery: Or side effects. If you look in your medicine cabinet, and you’re taking three pills, two sprays and a bunch of eye drops, it’s probably time to see the allergist.

Can that have a deleterious effect on your health, if you’re taking too many antihistamines and drops? Cella: Sure. Some of the antihistamines are sedating, a lot of the newer ones aren’t. Even with the newer antihistamines, men can get prostate issues. Sometimes they’re too drying. Sometimes they can interfere with other meds. They’re releasing some of the prescription nose sprays over the counter—those are inter-nasal steroids. Those can work well, but you can get raised intraocular pressures, glaucoma, nosebleeds, variety of other things. I’m actually surprised they’re releasing this stuff over the counter and yet other meds that should be over the counter are kept prescription. Berkes: Ultimately there’s been a frame shift in my patients. By the time they come to me, they don’t want another prescription. I find that great. I’m ready to do my best to find the root cause of the issue. It’s not a fast process, but it is entirely doable. That’s the wonderful thing that we allergists can offer: We can work with the immune system to fix something that has gone awry. We can do it with essentially natural extract, which is fantastic. We can do it with the hair of the dog that bit you.

What’s the testing and diagnosis process like for a new patient? Cella: One thing we do is skin tests, where you take the allergen and either prick the skin or do a little injection right under the skin. You can do blood tests if they’re at a good lab. Aresery: It’s really pretty painless, it’s quick and easy, you get an answer before you walk out the door as to what you’re allergic to. I don’t know where this myth has come up that this is a tedious, painful process, but it really isn’t. We test kids down to any age—there really isn’t any limit as far as where it comes to age group we might potentially be testing. Berkes: We generally don’t use needles. People might be afraid we’ll be using some 19th century technique with big, pokey needles; we don’t even use needles. Cella: More like plastic toothpicks.

When you have a new patient and you start the desensitization, what is the likelihood of being successful, and can you estimate how long it will take? Cella: It’s pretty standard at 60 to 80 percent for environmental allergies. First year’s really a build-up, a wait-and-see kind of thing. You can do it rapidly, but you can get more allergic reactions, or you can do it slowly, about once or twice a week, and that’ll make it about six months or so. Then it starts getting spaced out to two weeks, or some people go to four weeks right away. Total saturation takes about three to five years and once you’re off the shots, the immunity tends to last a long time. Aresery: The national recommendation for getting shots is three to five years. That’s the magic timeframe. If someone’s been on the shots for 15 or 20 years, I say maybe it’s time to step back, take them off and see how they’re doing.

How do people know that what they’re experiencing is an allergic reaction and not just bad food? Berkes: A lot of it is timing, some of it is type of symptoms. Symptoms should typically be histamine-mediated. Generally it’s itching, hives and it’s where the food makes physical contact in the mouth and the throat. Timing is critical; food-related reactions are not usually a delayed response, meaning after two hours. I usually tell my patients, you can tell me exactly what you’re allergic to because it’s a stereotypical response, meaning it happens the same way every time. Very rarely are there skipped times. Cella: You’re going to get the usual larger symptoms that we were talking about before—itchy mouth, rash, sometimes swelling of the mouth, gastrointestinal symptoms, wheezing, that sort of thing.

Why is the peanut allergy so prevalent? Cella: We eat a lot of peanuts in the U.S. If you go overseas, it’s something else. If you go to the Middle East, it’s going to be sesame. If you go to Scandinavia, it’s going to be fish. A lot of it’s what our society tends to promote food-wise. Aresery: It may also be partly related to how the peanuts are processed here in the U.S. versus in another country. The incidence of it is partly related to how much we’re eating it, but in other countries where they do eat it, where they process it a different way, they may not have the same level of allergy.

What do you think is behind the rise of gluten sensitivity? Cella: We’ll see it occasionally, but to me it’s a rare thing. Berkes: Actually, it may be related to the “Hygiene Hypothesis,” and the fact that about a third of what used to be our microbial GI tract is now gone.

What happened? That sounds alarming. A third of our GI tract biome is gone? Berkes: The normal exercise of our immune response is now skewed because we are missing this stimulation of a combination of infection, breast feeding, normal birth, etc. We’re skewed towards an autoimmune response, which is part of the reason for the allergic epidemic: 300 percent increase in allergic disease in the past 30 or 40 years. Essentially, industrialized nations, because of a multitude of factors have annihilated, over the generations, the normal mass of microorganisms that live in and on our bodies. One of the largest and initial places our bodies react to the outside is in the GI tract. According to Martin Blaser, a microbiome expert with the Infectious Diseases Society of America, about 30 percent of our normal microbiota is gone, which means that we’re incapable of responding normally. What does that have to do with responding to things like wheat? Our GI tract tweaks whether we go to inflammation or not. It’s all an immune response.

So with the rising gluten sensitivity, do you think it’s mostly legitimate, or just a trendy thing? Cella: It’s trendy. Berkes: People are more conscious of it. I don’t think it’s so much trendy as it is potentially real. Cella: Is there really any data to show that there’s an increase in incidence? Berkes: There’s data to show that there’s increased GI tract inflammation. Cella: Maybe so, but not necessarily with gluten. It’s low incidence, it’s trendy, it’s higher calories, the companies can make more money by saying it’s gluten-free. And a lot of people put themselves in a difficult situation trying to avoid gluten when they don’t need to. There are plenty of tests to determine whether they are sensitive to gluten or not, or whether they have celiac disease. It would make more sense to do that than for someone to engage in lifelong gluten avoidance. Berkes: How do you explain the increased incidence of people with Eosinophilic Esophagitis GI disease? Aresery: The one thing that’s interesting, without going into this, picking either side, is that probably 10 years ago, we had some other diseases that we were seeing. For example, when I was in training, we got trained on latex allergies, because there were tons of people—healthcare workers—that were coming in with latex allergies, or complaints of it. And now I almost never see it. Berkes: I do. Aresery: I see it sometimes, but not nearly as much as a long time ago. And now, things like Eosinophilic Esophagitis I never even heard of when I was in training. There are definitely changes in the diseases that we’re seeing. Perhaps because we didn’t know what they were before, or just being discovered, characterized. There are certainly shifts in some of the things that we see in our practices, all of us, I would say.

What do you see coming down the pipeline as to the future of your practice? Berkes: Sublingual immunotherapy, which is allergy drops under the tongue. Cella: That’s the new thing they’ve been doing in Europe that we’ve been talking about. Berkes: We do evidence-based sublingual immunotherapy, which is really exciting. We started that in the last year, and it’s really working well for our patients. It’s incredibly difficult for the average patient to come to the office over and over again until they get to the monthly shots. Aresery: There are two things I think of in terms of future therapies in our field. One of them is something John mentioned, which was desensitization to foods. It’s not quite ready for prime time, which means it’s pretty much being done at the university level, but at some point it will translate to the clinical. And the other big thing we call monoclonal antibody therapy. There are more and more drugs being produced, not just in the field of allergy, where you’re really targeting specific molecules or pathways in the system to try to treat a disease process. And this is where allergy is going, these monoclonal antibodies directed at specific targets. Unfortunately, they’re rather expensive.

Is there any time when people can stop worrying about developing allergies? Cella: Any time. It’s just a function of exposure. Like Matt was saying, some people are going to develop them, some people won’t. Berkes: Incidence does decline, though, in the 50s and 60s. Cella: It does. But then, we’ll have 80 year-olds with environmental allergies that are significant.

Do they become more dangerous as you get older? Cella: No. ­­

JOHN CELLA, M.D. Allergy Affiliates
A graduate from Princeton University and the Royal College of Physicians and Surgeons, Cella completed his residency in internal medicine at Columbia College of Physicians and Surgeons before a fellowship in adult and pediatric allergy and immunology at the University of California, Irvine. Board-certified in Internal Medicine, Cella is a fellow of the American College of Allergy, Asthma and Immunology.

MATTHEW ARESERY, M.D. Intercostal Allergy and Asthma
Board-certified in allergy and asthma, Aresery received his medical degree from Temple University, spent his residency at Reading Hospital and Medical Center in Pennsylvania and completed a fellowship in allergy and immunology at Tulane University before joining Intercoastal Medical Group Lakewood Ranch.

EVA A. BERKES, M.D. Hawthorne Clinic and Research Center
Berkes received her medical degree from the University of Florida, where she also completed her residency in internal medicine. After a fellowship in allergy, asthma and immunology at The Scripps Clinic and Research Institute in La Jolla, Caliornia, Berkes returned to the Sarasota-Bradenton area to start her own practice. SRQ